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Cardiac arrhythmia triggered by diuretic-induced hyponatremia

Lu HT, Loo HC, Ng KS, Wong YO, Nordin R

Malays Fam Physician, 2019;14(2):39-43.
PMID: 31827736

Diuretics have a long and distinguished history in the treatment of hypertension and heart failure. Clinical practice guidelines recommend that diuretics should be considered to be as suitable as other antihypertensive agents for the initiation and maintenance of antihypertensive treatment. However, diuretics may potentially cause electrolyte disturbances and metabolic side effects. Diuretic-induced hyponatremia is probably more prevalent than generally acknowledged. We present an unusual case of indapamide-induced hyponatremia and hypokalemia complicated by cardiac arrhythmia. The adverse drug reaction was reversible and non-life-threatening, but this case serves as a reminder that careful evaluation and constant monitoring are necessary when prescribing diuretics.

Matched MeSH terms: Hyponatremia
Fulltext Risk of acute kidney injury and hyponatremia in long-distance runners

Abdullah R., Wan Md Adnan W.A.H.

JUMMEC, 2018;21(2):4-9.
MyJurnal

Long-distance running has gathered some momentum among health-conscious participants. However, some
studies have revealed association between long-distance running and development of acute kidney injury.
Although the impact usually lasts only for a few days after the event, some participants have been admitted for
severe acute kidney injury, the minority of which require dialysis treatment. The mechanisms underlying the
injury may include dehydration, development of rhabdomyolysis, heat stroke and concomitant use of NSAIDS.
Unfortunately, there is no long-term follow-up study to determine the long-term effect on kidney function.
Acute hyponatremia may develop in a significant proportion of long-distance runners. Majority of them were
asymptomatic but a few fatal cases which were supposedly due to cerebral oedema have been reported.
Excessive intake of hypotonic drinks, excessive sweating and secretion of non-osmotic antidiuretic hormone
have been postulated to be the causes of hyponatremia. This mini review will discuss the pathophysiology of
the development of acute kidney injury and hyponatremia. It will also discuss the prevention and treatment
of both conditions.

Matched MeSH terms: Hyponatremia
Fulltext Pontine myelinolysis following correction of hyponatraemia

Loo CS, Lim TO, Fan KS, Murad Z, Suleiman AB

Med J Malaysia, 1995 Jun;50(2):180-2.
PMID: 7565192

A patient with severe hyponatreamia secondary to chronic renal failure was treated with peritoneal dialysis (PD). On the third day of admission, she developed progressive obtundation. Neurological examination showed bilateral brisk reflexes with intact brain stem reflexes. Magnetic resonance imaging demonstrated patchy demyelination of the pontine area indicating central pontine myelinolysis (CPM). Despite supportive measures, the patient died on the fifteenth day of admission. The rate of correction of hyponatraemia with peritoneal dialysis can be rapid and detrimental to hyponatraemic chronic renal failure patients and careful monitoring of serum sodium level is advocated.

Matched MeSH terms: Hyponatremia/therapy*
Dengue Encephalitis associated with symptomatic hyponatremia due to Syndrome of Inappropriate Antidiuretic Hormone Secretion

Ng WW, Cheong BMK

Med J Malaysia, 2021 03;76(2):261-263.
PMID: 33742642

A previously well 21-year-old girl presented to Hospital Teluk Intan, Perak, Malaysia with a short history of fever, vomiting and altered sensorium. She was diagnosed with dengue encephalitis as her dengue NS-1 antigen was positive and her cerebrospinal fluid (CSF) dengue polymerase chain reaction (PCR) was positive with serotype DENV-2. She also had severe hyponatremia due to Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) which caused an episode of seizure. She recovered well with supportive management. SIADH and dengue encephalitis should be considered as one of the differential diagnosis in patients presenting with fever and altered sensorium especially in dengue endemic countries like Malaysia.

Matched MeSH terms: Hyponatremia
Fulltext Case Report: Severe Hyponatremia in Infants With Urinary Tract Infection

Abu Bakar K, Jalaludin MY, Zainal N, Woon SL, Mohd Zikre N, Samingan N, et al.

Front Pediatr, 2021;9:655010.
PMID: 34026690 DOI: 10.3389/fped.2021.655010

Introduction: Many reports on investigations and treatments in UTI, however little, have been mentioned with regard to electrolyte abnormalities. Secondary pseudohypoaldosteronism (PHA) in UTI, though less common, is a known association. Features include hyponatremia and concomitant hyperkalemia. Objectives: We aim to highlight these uncommon sequelae in UTI to avoid incorrect diagnosis and unnecessary investigations. Study Design: Clinical data of patients admitted and referred to a pediatric nephrologist at the University Malaya Medical Center between May 2019 and October 2020 were collated and elaborated. Results and Discussion: We report three infants with hyponatremia and hyperkalemia during UTI episodes. Two infants were known to have posterior urethral valve (PUV) before the onset of UTI and one infant had UTI, which led to investigations confirming the diagnosis of bladder vaginal fistula. The electrolyte derangements were temporary and resolved within 48 to 72 h of treatment with intravenous fluid and appropriate antibiotic therapy. Out of three, only one had a hormonal study, which confirms PHA. Reduced aldosterone activity could be due to absolute reduction in aldosterone titer or lack of aldosterone responsiveness at tubular (other tissues) level. In the latter, aldosterone titer is elevated. The infant in our cohort who had hormonal evaluation had the mentioned electrolyte abnormalities with a markedly elevated aldosterone titer. This demonstrated defective action of the hormone at the level of mineralocorticoid receptor. Although the remaining two infants had no confirmatory hormonal study, all of them recovered within 48 h of hospital admission, after receiving appropriate management for the primary problem, which was UTI. We observed a slower recovery of hyponatremia in relation to hyperkalemia, but none of these infants required salt replacement upon discharge. Conclusion: Infants with severe UTI and deranged electrolytes should be screened for structural abnormality and vice versa. Not all infants require hormonal screening, but those who required prolonged salt replacement or showed involvement of other systems warrant further evaluation.

Matched MeSH terms: Hyponatremia
Fulltext Pyoderma gangrenosum and cobalamin deficiency in systemic lupus erythematosus: a rare but non fortuitous association

Teoh SC, Sim CY, Chuah SL, Kok V, Teh CL

BMC Rheumatol, 2021 Mar 03;5(1):7.
PMID: 33653418 DOI: 10.1186/s41927-021-00177-4

BACKGROUND: Pyoderma gangrenosum (PG) is an uncommon, idiopathic, ulcerative neutrophilic dermatosis. In many cases, PG is associated with a wide variety of different disorders but SLE in association with PG is relatively uncommon. In this article we present the case of a middle aged patient with PG as the initial clinical presentation of SLE. We also provide a brief review of cobalamin deficiency which occurred in our patient and evidence-based management options.
CASE PRESENTATION: A 35 years old man presented with a 5 month history of debilitating painful lower limb and scrotal ulcers. This was associated with polyarthralgia and morning stiffness involving both hands. He also complained of swallowing difficulties. He had unintentional weight loss of 10 kg and fatigue. Physical examination revealed alopecia, multiple cervical lymphadenopathies, bilateral parotid gland enlargement and atrophic glossitis. There was Raynaud's phenomenon noted over both hands and generalised hyper-pigmented fragile skin. Laboratory results disclosed anaemia, leukopenia, hyponatraemia and hypocortisolism. Detailed anaemic workup revealed low serum ferritin and cobalamin level. The autoimmune screen showed positive ANA, anti SmD1, anti SS-A/Ro 52, anti SSA/Ro 60, anti U1-snRNP with low complement levels. Upper gastrointestinal endoscopy with biopsies confirmed atrophic gastritis and duodenitis. Intrinsic factor antibodies and anti-tissue transglutaminase IgA were all negative. Punch biopsies of the leg ulcer showed neutrophilic dermatosis consistent with pyoderma gangrenosum. Based on the clinical findings and positive immunologic studies, he was diagnosed as systemic lupus erythematosus. His general condition improved substantially with commencement of corticosteroids, immunosuppressants and vitamin supplements.
CONCLUSIONS: We report a case of PG as the first manifestation of SLE which was treated successfully with immunosuppressants and vitamin supplements. Our report highlighted the need to consider connective tissue diseases such as SLE in a patient presenting with PG in order for appropriate treatment to be instituted thereby achieving a good outcome.

Matched MeSH terms: Hyponatremia